MSF missions take a massive amount of coordination and effort, spanning several continents in real-time, which in turn can be intense, complicated and trying. I’ve made mention before of the logistical concerns of putting up to 60 staff on the ground in Tacloban soon after the super-typhoon. Attending to personal needs of the humanitarian staff continues apace while sourcing out a place to set up a hospital, hiring staff, and getting everything from surgical amphitheatres, neonatal units, mobile/outreach clinics, and mental health services up and running.

Then the first patient steps through the tent flap of the outpatient department and is told that they will be assessed and treated without cost for these services and medications provided.

At times, the bodily needs are easier to understand than mental health needs. We see a broken bone, hear the cough, and can measure the blood-glucose level. The reasons that one comes to mental health care attention are often due to conspicuous absences of functioning at home, socially, or at work or school. In children, especially. A quiet child, decrease in concentration or attention, fearfulness at night and some avoidance of social play… these things could go unrecognized.

The elementary school program was set up prior to my arrival. It is finishing this week, as the Tacloban Project is in its termination phase, and the school children go on break at the end of March. This was an ambitious project, and by that I mean it was a well-thought-out, resource-intensive, and focused intervention. That MSF has in place the will, technical expertise and resources to undertake this mission is one of the reasons that I have come back for a third mission with them.

A psychiatrist was included in one of the early waves of staff on the ground, and she did a quick but thorough assessment of the community needs while getting the program started. Soon after a child psychiatrist and psychologist were hired, and they did the legwork of working with the local health and education authorities toward identifying schools and children in need of psychological services.

Enter Sherman, the irritable Raccoon. Not a typo.

The children, about ten per session, huddle in a circle while one of our staff reads from this storybook, “A Terrible Thing Happened” by Mararet Holmes.

The students come from two coastal elementary schools which were identified as the hardest hit by the typhoon. The numbers are staggering. 67 children died in the one school, which represented about 15% of the total 425 students. 37 students died of 287 in the other school. Words fail when trying to capture the tragedy, and the heartbreak.

Beside the school, in front of the neighbourhood church, is a makeshift cemetery. The kids, their families, and teachers walk by it every day.

And this is where Sherman comes in. Something bad happened to the young Raccoon, and he begins to show signs of fear, stress, and acting-out behaviour. There are four sessions with each group, the first three involve reading the first, second and final third of the storybook.

After the first session, the children are asked to draw on paper what Sherman may be afraid of. After the second, where it is shown that Sherman is having some difficulty in school and with friends/family, and tries ways to calm himself, the children are asked how Sherman is coping with the “very bad thing,” and how he is finding ways to self-soothe or pacify his inner turmoil. The final third of the book involves a therapist that Sherman talks to, and eventually he feels better. The children are asked to draw their thoughts about Sherman now that he feels better, and what Sherman might do with his re-found happiness.

The children explain to one of our four program staff the meaning of their drawings, and the themes are tracked throughout the four weeks. It is a therapeutic process on its own, but when some students are clearly exhibiting a decline in school functioning (sometimes to the point of refusing to attend school), more intensive work is done. Caregivers and teachers are consulted and the child is rated on an MSF-generated cross-culturally validated tool called the PSYCa, to identify what symptoms are evident and should be targeted. Individual therapy is done with the child and caregivers.

“Sherman saw three ghosts and he was scared of ghosts. He stays in the house to stay away from ghosts.”

“Sherman saw a dead person beside a tree where it was buried. He is scared of dead people. Sometimes he prays for the dead who are already in heaven. Sherman stays inside his home brushing his teeth”

“There are dead people buried outside the house of Sherman, but he is not scared of them. He just plays inside the house with his dog.”

“The three figures in the mountain are zombies looking for victims but they won’t find any because there is no one in the mountain. The little house is Sherman’s where he saw the monster Caswarg. But he prayed and went to his mother and father after he saw the Caswarg, and that’s why he is not afraid anymore.”

As the weeks have passed, and the students in need of individual attention decrease, our program is coming to a close.

The wind and rain comes and the children still exhibit some hesitancy or fear, but it passes quickly for most, and a song is sung. Most students now run outside to play in the rain. The Principal, the teachers, the parents, they thank us for our work with their students, their children, their community. I tell them that this is why MSF is on the ground, and that it was a privilege to have been allowed into the schools and to do the therapeutic sessions with them. I tell them that this is why, in part, MSF is in the country. It is a feel-good moment.

Our project staff deserve the pride that they have taken in their work. Over 100 children per week took part in the storybook sessions, and five to ten per week had individual therapy.

Primary health care includes mental health care. If we don’t have staff who are knowledgeable and committed to mental health work, either in a disaster setting or in a longer-term crisis setting, we are missing suffering that is identifiable and treatable. That this is crucial work is as clear as day. To those who decided to get a mental health program off the ground quickly, think of the children who, when they come across ghosts or the monster Caswarg along their fantastical journeys, are no longer afraid and play outdoors.

The names and some details of the case have been changed to ensure anonymity. Melan provided permission to write about his story, with the understanding that it would be potentially read on the internet by people all over the world, and would describe some of his experiences of the previous several years. His mother provided written permission.

At around 11am on Saturday, I was asked to see an 11 year-old boy, Melan, who had been brought to the MSF Outpatient Department for a fever and sneezing. The physician who saw him was advised that since the typhoon, Melan has been more isolated and played less with friends, and thus made the referral to mental health services.

Melan looked like any boy his age. He had a mop of shaggy hair, jeans, and avoided eye contact most of the time. He peered up now and again, and had a sad look that wouldn’t shake. I told him that he didn’t have to be here, that he could leave and come back another day, but it might be good for him to talk given the sadness his mother described. He thought it best to continue, despite his hesitancy. He wouldn’t speak for a little while, but eventually said that he has been “feeling down because of the storm.” Regarding his experience of the typhoon, he said that “the winds tore the roof open and trees fell down… tidal wave… many things happened.”

Melan’s mother watched with an uncomfortable anguish as he spoke through his tears, remaining silent yet present as he expressed himself.

He was in the family home, with his mother and cousin (age 6). He awoke around 5am when the roof-top ripped off his house. He had heard that a big storm was coming, but he thought it would be like the many other storms that he had witnessed, so he was not worried when he went to sleep. The first floor of the house flooded, and Melan joined his mother and cousin for the next four hours. He spoke with his mother throughout the storm, and he felt that she and he “were fine.” When the winds died down, he walked outside, and found that “many things were destroyed… electrical posts, houses, almost everything in the house, roads.” He thought that his house could have collapsed, as many others had. Melan did not see any dead bodies, but heard of casualties, and of others seeing bodies in the street.

Melan had no close friends or family who died in the storm, nor was anyone in his school injured or killed.

After the Typhoon, like so many others, Melan and his mother went to Manila to stay with family. He felt safe in Manila, and thought of the storm “sometimes.” He returned to Tacloban five days prior to having presented to the MSF hospital. He was sleeping relatively well, and had no nightmares, but thought of the storm during the daytime “sometimes.” He could go many hours without any thoughts of the storm. As he said this, however, tears washed down his cheeks. I asked where the tears were from, and he answered, “the people who were killed in the destruction.” He could not identify who, just that they were people from his city.

At this point his mother was crying quietly, and I was quite taken with his story. It was becoming less clear, however, what was driving his sadness and self-isolating behaviour three months after the incident. Melan had no psych history, was on no medications and had an unremarkable medical history. Nobody in his family had ever been seen by psychological services of any kind.

I asked Melan if the darkening clouds, rain and winds were worrying to him, and he said that they were not. When asked what he would say to a younger child if they were frightened in a storm, he responded: “calm down, there is nothing to be afraid of.” And he reiterated that this was his belief, not simply the consolation of an innocent. Melan did not recall having been frightened by a storm or any other act of nature prior to or since typhoon Yolanda.

The most difficult part of the memory of the typhoon was “the part where many people died… the part that friends or family could die… I could be alone.”

This could be called existential angst. Death and loneliness drive many symptoms, but as the discussion continued, it did not seem to be the generator of his almost palpable terror. And then it came out. When asked if there was any time in his life when Melan felt alone, powerless to what could happen next, he started to cry more forcefully, sometimes gulping air as he spoke. It was wrenching to me, and his mother put an arm around him as he continued. He spoke of the time when he was 7, and a 10 year-old male student “punched him” once and taunted him several times. This bullying behaviour took place at and around school-time, and lasted about 1-2 months.

Melan refused to go to school a few times, but his parents and teachers were, to his recollection, unaware of the problem. The bully did not target Melan specifically, as he was known to bully the younger kids. On direct questioning, Melan said that the bully probably did not even know his name, and the bullying stopped because the older boy forgot about Melan.

We spoke about feelings of helplessness and fear given circumstances out of our control. Melan cried a fair bit, but decided to continue.

We spoke of his father who had been a migrant worker in Dubai for 8 years, and how he has a good relationship with him, speaking on the phone every week, and seeing him once a year for a week.

Melan’s plan for the near future was to “be with friends this week… try to forget about the past… not think of bullying.” We set up an appointment for the following week.

This story hints at many things. I want to underscore something that has become glaringly apparent as time goes on in my career and life: that a sizeable chunk of human misery is perpetuated by factors within someone’s control, often discretionary.

The jeepney sets out at about 8:15am. It looks like a battered old short-bus, but instead of back seats, it has two long bench seats along the sides, and an open back and sides. If there is no air conditioning, this is the most comfortable way to travel.

Three counsellors. One of whom is an MD, the other two have an undergraduate degree in psychology. All have had previous training with another MSF project in the Philippines. We’re constantly bantering and discussing cases along the way.

First we attend Tanauan Central School Evacuation Centre. There had been a planned time for follow-up sessions with some persons identified as having difficulty adjusting to post-typhoon conditions, whether above the threshold for a diagnosis of mental illness or not. The tent city locale was empty. Almost completely empty, in that there were even no kids about, which is a rare thing out here. Turns out that the whole camp had gone to a place called Pago to work on the more permanent structures to where they would be moving eventually.

We moved on to a small displaced persons camp, mostly made of up tents. We met with the Captain of the local region, and he warmly greeted us, but advised that there was a food distribution going on, which clearly took priority over the planned psycho-education session that we had arranged. We rescheduled for that afternoon, and hopped in the Jeepney toward the next stop.

The Assumption evacuation centre was similarly empty. Again, the inhabitants had gone to Pago to work on the housing structures there.

So we decided to do the most expedient thing and headed to Pago. There was a single concrete structure erected, and the start of many others. Building materials were stacked up in neat, organized piles. Large groups of people were working on different projects: moving wood, cleaning metal beams, concrete mixing, brick-laying, etc.

The MSF counsellors split up to find the persons with whom they had follow-up sessions planned, and they retreated under the shade of a tree to do their work. If possible, returning to work is almost always a good thing. It aids with depressive and anxious symptoms, of which post-traumatic distress is included. Work tends to be social and provides a sense of purpose, worth, and community-building.

The housing units are provided in order of need, and there is an equation that takes into account the size of the family, number of children, destruction of property, distance from shoreline, and other factors. My small poll suggested that most people thought that this was fair, and that they wanted to move in as soon as possible.

Next stop lunch. We ate, discussed the cases, and planned the afternoon. Fish, rice, some meat stew that might have been pork. Like most prepared food here, there is too much sugar and salt. The fish was fantastic. The lunch room was a small open-air establishment that had been built mainly since the typhoon. On one side was the road with cars driving by, and on all other sides the visible debris from the storm. It had been arranged into piles of metal sheeting, wood that seemed to come from docks, and broken cars and other forms of transportation that had been destroyed. The region, Bislig, is one that was hard-hit, and is also being targeted by our Outreach team.

We then returned to Magay for that psychoeducation centre. A bell was rung and the milling-about crowd grew from 20 to over 100 persons. It was a lively group. Many mothers holding babies, some who had been born since the storm. The Barangay Captain, a white-haired septuagenarian fellow who wore crisp jeans and a jean-shirt, curiously unaffected by the blistering heat and humidity, introduced our team. The counsellors launched into their routine, which was in the local dialect of Tagalog, called Waray Waray. One of the counsellors translated some of the on-goings, but more than anything I was fixed by the cadence and energy of the group. It was fast, interactive, and thoroughly engaging to the participants. The group called out answers to questions, made comments that struck home to easy laughter, and asked for clarification if the need arose. It was warm and intimate. I want to write that it had this tenor “despite” the setting, which was a slightly shaded area, 20 or so seats, with the rest of the people standing. But of course, it had almost everything to do with the setting.

Psychoeducation sessions are necessary here. It is very common to have people brought to the hospital by family for non-specific or unexplained medical symptoms such as bodily aches, irritability, sleep problems, and decreased functioning in the social, family or work sphere. No mention of sadness and anxiety is made, but on inquiry, there is significant concern in these areas. There are also more cases than I would have suspected involving persons who have been psychotic for years, and were never brought to the attention of a mental health professional. Some teaching of common symptoms of mental illness, and the availability of free MSF services, is a good thing. Of course, one wants to be aware of local ways of expressing emotions and behaviours associated with illness (idioms of distress and styles of reasoning), as we don’t want to prime people how to “properly” exhibit illness. But it seems that even moderate to severe symptoms may go unrecognized and unattended to by available health resources. There is much more to say on this topic, but I’ll leave it there for now. Something interesting happened.

At one moment during the 20-minute session, one of the counsellors asked the group if anyone had a family member or someone close to them who was killed by Typhoon Yolanda. There were many hands that went up. Then someone made a comment that got everyone laughing, and some were looking at a 60-ish year-old woman who was in the front row. She laughed, turned a bit red from the attention, and then started to cry. She covered her face, but motioned that she was ok, and for the talk to continue. The counsellor went to stand beside her, put a hand on her shoulder, as had several others who were sitting beside her or standing near her. The counsellor continued the session, and after a few minutes moved back to a central location. When the session was over, the counsellor sat down beside her and they spoke for 15 minutes or so. There were about three or four women who had pulled up chairs to take part in the discussion.

It was explained to me afterwards what happened. The woman’s name was the international call-sign name of the storm, and her husband died in the typhoon. When the group was asked if anyone was killed by “Yolanda,” someone joked that she had killed her husband. I double-checked that I heard that correctly. It’s hard to imagine a large setting in which humour like this wouldn’t be off-side back home in Canada.

I work at a Toronto hospital called the Centre for Addiction and Mental Health (CAMH). It’s one of the largest mental health institutions in the country. I could not even fathom humour such as this being mobilized in this way, but I started to wonder what it would take. I’m still wondering.

Here in Tacloban city and environs, in this most remarkable of places, humour is used with great deftness in the integration of psychologically traumatic events in a coherent and tolerable narrative. This is healing behaviour. It struck me that this was a shining example of the concept of resiliency.

(The winds hit gusts of 365km per hour; many stores that have reopened include the name Yolanda.)

I went this morning to see “the boats.” I had been asked several times if I’d seen them, so I got the sense that it was something to behold. I saw a few photos on the web, but it was hard to place the ships among the heaps of detritus from the storm.

The boats are massive. Bigger than the MSF staff housing structure that comfortably sleeps well over 20. Bigger than a standard sized apartment complex. The water surge brought them inland and then left them there after it retreated, simple as that. To ensure that they don’t topple over, stabilizing wedges have been put in. You have to crawl under one section of one boat’s hull to continue down one of the roads. It’s a bit freaky.

A fellow named Manolo came to chat with me. The Filipinos are near uniformly friendly. He asked me where I was from and who I worked with. Oddly enough, when I told him that I worked for MSF and we had a full hospital providing free medical care, notably dispensing no-cost medications, he was unaware of this. We joked about basketball with his friends, and then I set off. He thanked me for coming to his country and helping his people. It still shocks me how gracious the Filipinos are for humanitarian assistance. There are signs randomly strewn around town indicating such salutary sentiment.

It probably speaks to my cautiousness that I suspected the teenager to be a tout, which in most countries means he befriends you, shows an interest, tells you some facts and then asks you for money.

Not here. I walked around for an hour seeing the five or so boats that were abnormally hulking on land. Not once was I asked for anything. But the kids smile and yell out, and adults say “good morning” or some other greeting in a warm manner.

This is not a unique sensation amongst the staff, I’m finding. The consensus is that this is a kind, welcoming, and honest place. To underscore the point, I thought that I had left my cell phone somewhere the day before. I went back there with a local MSF staff fellow to help me translate, and he said something of the order of: “you will probably get it back, people are honest here.” Not since travelling in Japan have I found a place like that.

The contrast between life-as-usual playful staff and friendly interaction, immediately counter-posed with the evident destruction and loss of life in the typhoon, is hard to reconcile. It’s as jarring as a massive boat in the middle of the street. I’ve never been exposed to the aftermath of a calamity, but I did not expect the resiliency of the Filipino community to be this pronounced.

A small convoy of people were coming through the MSF hospital space, and I said hello to a man and woman. They responded with an American accent on their English, and stopped me to talk. Turns out that they had Filipino heritage, but had grown up in New Jersey. They had donated some money to the project, and were coming by to see it. The woman asked me if I had found a lot of PTSD (her word), and I stated that there was some, but less than I had expected. She said, “yes, we are very resilient.” A few more minutes of talking revealed that she and her husband were doctors, herself a psychiatrist. She knew from whenst she spoke.

There are always some clinical anomalies. Here, it seems that it is trauma-induced psychosis. This is a rather rare phenomenon, showing up for brief periods after rather extreme stresses on the body (lack of sleep, dehydration, sustained high stress). Often this occurs in persons with a vulnerability to psychosis (they have had bouts of paranoia in the past, during periods of high stress, substance use, or just spontaneously). But I have now seen three cases which developed with seemingly no pre-Typhoon psychiatric history. In otherwise highly functioning people, frank auditory hallucinations and paranoia have developed post-typhoon. Common symptoms to all three involve hearing the voices of dead people, and thinking that someone is going to come and kill them. Family support, sleep, antipsychotic medications, and close follow-up have been effective, but the psychosis is lasting longer than expected. Something to ask the local psychiatrists about when I see them next.

Another odd thing. There is no word in Tacloban that I have heard that means “foreigner.” Kids yell out “sankai” which translates to “friend.” While there may very well be one or more, it is notable that in two weeks of being on the ground, I do not know it. This is contrast with other regions that clearly demarcate in-group and out-group members. In Canada we have a unique politics of identity. It makes very little sense to say that someone is “not Canadian.” If I meet someone on the street or in the hospital and ask them where they are from, and they respond with the only three English words at their disposal: “I am Canadian,” I could very well smile and say, yeah, but where were you before here. Un-Canadian behaviour would be someone who was being unfair or culturally insensitive. The Canada I know seems to pride itself on being inclusive. Or, said differently, we have a rather weak politics of exclusion. The sense of inclusiveness here in the The Philippines is a marvel, and, if I can say, more pronounced than any place I have yet been.

This blog is mirrored from the MSF site. Pictures are added. Date of initial publication: February 18, 2014.

This blog is mainly to get word out to friends and family regarding this mission. There are a lot of questions coming my way, the answers to which may be of interest to some and not others. From conditions on the ground involving lodging, food and security on to the impact of physical and psychological trauma on the local population, and how the project is addressing these needs. Somebody asked me how I brought enough toothpaste for 2.5 months, given that I had a strict 10k checked-luggage weight limit. That’s ok. I’m posting this openly as others may be interested in what an MSF mission to the Philippines is like for a rank-and-file forensic psychiatrist from Toronto.

Happy reading, whoever you are. Your time is appreciated.

But please keep in mind that this blog is personal, and in no way is meant to represent the views or organizational values of MSF. I wholly support the MSF that I know to be an independent, politically neutral organization that provides medical care irrespective of race, religion creed or political conviction. If you walk in the door, and are in need of help, MSF does its best to help. This is my third mission with this organization, and it is a pleasure and an honour to work with them again.

Onwards…

Human-caused climate change likely had something to do with the “super-typhoon” on November 8, 2013 that tore a strip off of regions of the Philippines. Winds of over 300km/h, and gusts well higher, made this the most powerful such storm ever recorded to make land-fall. And it did. It was as if not a single building was left standing in some regions, by reports, photos, and remaining carnage evident. Tacloban was one of those hard-hit regions. A city of about 200,000 people, it is on Leyte Province, in the Visayas. I arrived on February 8, three months afterward the typhoon.

Filipinos are accustomed to storms with high winds, but this was something new. Not only were the gale forces well in excess of the near-monthly storms that come through, it was the unexpected rise in sea level, 4 metres high in some regions, that caused so much loss of life and other damage. Tacloban is at the crux of an inlet, so the water brought by the typhoon was amplified. The death toll is not clear, but it is over 7 thousand. Millions were affected.

MSF was on the ground in in the Philippines within several days, but as is the case in calamities, putting resources on the ground is only half the battle. Distributing them is the other. Infrastructure (roads, communications, water and sewage, power sources and lines) were wiped out.

The Wikipedia site describes the scene as follows:

According to estimates on November 13, only 20 percent of the affected population in Tacloban City was receiving aid. With lack of access to clean water, some residents dug up water pipes and boiled water from there in order to survive. Thousands of people sought to evacuate the city via C-130 cargo planes, however, the slow process fueled further aggravation. Reports of escaped prisoners raping women in the city prompted a further urgency to evacuate. One resident was quoted as saying “Tacloban is a dead city.”[61] Due to the lack of electricity, planes could only operate during the daylight, further slowing the evacuations. At dawn on November 12, thousands of people broke through fences and rushed planes only to be forced back by police and military personnel. A similar incident occurred later that day as a U.S. cargo plane was landing.[92]

On November 14, a correspondent from the BBC reported Tacloban to be a “war zone,” although the situation soon stabilized when the presence of government law enforcement was increased. Safety concerns prompted several relief agencies to back out of the operation, and some United Nations staff were pulled out for safety reasons. A message circulating among the agencies urged them to not go into Tacloban for this reason.[93]

MSF has set up services in a hospital that was previously damaged. They are fixing the structure so that is is usable and safe for MSF staff, and have hired many who were in its employ prior to the typhoon. Functioning six days a week, they saw over 2500 patients last week in the outpatient department. There are about 50 inpatients, which include surgical cases and maternity. Last week there were 57 admissions on the maternity ward, which was over capacity, so several new beds were added. MSF provides free care and medicine,,so the numbers of people using our services are swelling.

I’ll be speaking about the mental health project more, but briefly, there are three components:

Outpatient department (OPD): referrals from other services and our own follow-up

School Program: Set up by child psychiatrists and psychologists, this ambitious project works with teachers and caregivers in elementary schools hard-hit by the typhoon. Just to provide the scope of the destruction caused by the storm, one school which I attended last week had 63 students (30 male, 33 female; and one teacher) killed. This was from a census of 430 students (grades 1-6) and 17 teachers. (Correction, there were 67 students killed at the school… the final count changed as more bodies were discovered since this number was first written.)

We have one psychiatrist, one psychologist, 8 counsellors and two translators. Individual assessment and counselling are offered, which makes MSF, I’m told, perhaps the only NGO (non-governmental organization) to offer such services in the region.

When I was at the elementary school, the skies darkened and it started to rain. The winds picked up ever so slightly. A fright that I have never seen before en masse in children set in quickly. They jumped up and huddled in the corner and cried; school teachers and our staff attended some of the more distraught ones. One child ran toward her house, inconsolable.

It is hard to transition from such anguish. But this post is to capture a brief snapshot of the project, and then return to mental health and some other issues more fully.

I’ve never seen an MSF project that was not ambitious. This project is ambitious. Some details.

There are, now, around 15-20 expat staff (like me who have been brought in from outside the country), and a much larger number of local doctors, nurses, midwives, pharmacists, etc. I should get numbers, but suffice it to say that this is fair-sized facility.

The logistics of putting so many supplies on the ground, navigating the decimated infrastructure, and arranging these medical services, is nothing short of staggeringly impressive.

Two quick examples.

The hospital’s electrical system was shot through when the typhoon hit. In addition to the electrical grid in the city going down, and all the hospital damage, the water level hit the second floor of the hospital. MSF rigged a complete second system of wiring and outlets within days of being in the building.

Second example: a few days ago I wrote on a requisition form that Mental Health Services (MHS) could use a flipchart and second whiteboard for teaching purposes, in addition to the markers, erasers and such that go along with this. Within less than 24 hours, a flipchart and 2 paper rolls, as well as a whiteboard, were set up in our group meeting room. The flipchart stand was constructed after the requisition was put in. That this is seen as standard service is, I say again, hellava impressive. Logistics is the unsung hero of MSF (at least from the outside; inside the NGO world and by all who work for the organization, their praises are sung).

The MSF project expat staff now live in a structure that used to be a hotel. Everybody except for the 4-5 staff (surgeon, anaesthesiologist, midwife, obstetrician, emerg doc; they’re on call, so that’s the rationale) share rooms. It’s a pretty swish location for MSF standards, with the local generator providing power for several hours in the morning and evening. We have people who cook, clean and provide security, so food is pretty healthy and plentiful, the house is safe, and so on.

Most of the staff are out of the house by about 7am, and arrive at the hospital within 15 minutes or so. We have several vehicles that provide transport, some of which are larger buses with open bench seating in the back, and more modest rickshaw-type units. The end of the day seems to be around 5-8pm, depending on the need. I’ve not left before 7pm, despite some messy jet-lag (it’s 13 hours ahead of Toronto). This was not really my desire, but things have been busy.

So there it is. I’m going to try and attach pictures, but internet is really spotty. We don’t have it at the house, but seemed to have had it for several hours yesterday at the hospital… narrow bandwidth. Not having internet is like having phantom limb discomfort. You just feel like that appendage should be there.

It must be said early on that the Filipinos have been a warm, welcoming, and generally wonderful population with whom to work. This is not the case everywhere, really.

OK. Toothpaste. I brought 50ml, assuming that since this was a large-ish city, I could find some here when I ran out. This is true now, but for the first month that MSF staff were on the ground, this was not the case. Finding food, clean water and other basics was a challenge for the first wave of MSF staff on the ground. I don’t know what they did. An emergency relief mission is a different thing than what we’re doing now. I greatly respect the efforts of the many staff (expat, local, distant) that carved out the project that allows me to fly in and immediately focus on mental health work.

Commentary #1: Bridging the Gaps for Former Inmates with Serious Mental Illness

Anthony C. Tamburello, MD, and Zoe¨ Selhi, MA, MD

Serious mental illness is a prominent and vexing problem within the correctional systems of North America. Simpson and colleagues draw attention to the epidemiology, special characteristics, and management problems relevant to Canadian inmates with serious mental illness. Of great interest to those in the forensic psychiatric field is the matter of continuation of care for mentally ill prisoners, in that untreated or under-treated psychiatric problems are strongly associated with poor social functioning and criminal recidivism. In this commentary, we expand on the discussion in Simpson et al. of the effectiveness of assertive community treatment teams for those former inmates at greatest risk for future involvement with the criminal justice system. We also propose outpatient civil commitment as one strategy to facilitate the successful return of select inmate patients to the community.

J Am Acad Psychiatry Law 41:510–3, 2013

Simpson and colleagues1 draw our attention to the epidemiology, special characteristics, and management of inmates with a serious mental illness (SMI) within the Canadian prison system. We think that this article identifies important shared clinical and academic interests for correctional psychiatrists in both the United States and Canada. First and foremost is their conclusion that SMI is common in correctional settings. As the authors point out, the seriously mentally ill are more likely to be incarcerated than admitted to a hospital2–4 for treatment. The corollary to this conclusion, confirmed by epidemiological research in both the United States and Canada, is that SMI is more prevalent in a correctional setting than it is in the community.5–9 As the SMI represent those most in need of psychiatric care for poor functioning, whether in a community10 or a prison setting,11 meeting these needs is critically important to all stakeholders.

Some aspects of the review by Simpson et al. limit its generalizability to prison systems. Most relevantly relevantly, their use of the term prison inmate refers to both pretrial detainees and those serving a sentence after criminal adjudication. Thus, data are included in their review on inmates who might be housed in a jail or detention center. Although the article at times points out which type of inmate was included in the cited study, interpretation of this information requires awareness of the differences between pretrial and sentenced inmates. First, the rate of mental illness in general, and serious mental illness in particular, may be moderately higher in jails than it is in prison. The most recent survey by the Bureau of Justice comparing the rate of mental illness in U.S. jails and prisons illustrates this point: psychotic symptoms were reported by approximately 24 percent of jail inmates versus 15 percent of state prisoners. 12 A second, related point mentioned by Simpson et al. includes the acuity level of mental illness in these two populations. Pretrial detainees are more likely to experience symptoms of their illness, given the predictable psychosocial stressors related to their recent incarceration and the uncertainty about their legal fate. The stress of their situation may explain the higher suicide rate observed in jails compared with that in prisons.13 Finally, although substance abuse was not the focus of Simpson et al., the rate of substance use disorders appears to be higher in inmates in jail than in their counterparts in state prison.14

It is hard to argue about the point that Simpson and colleagues make that SMI is a major problem for correctional psychiatrists and the systems in which they serve. The untreated or under-treated mentally ill are at greater risk for unemployment, homelessness, needing emergency services or hospitalization, substance abuse, suicide, being victims of crime, engaging in violence toward others, and poor quality of life.15,16 They have a shorter life expectancy, most likely related to a combination of under-treated medical problems, unhealthful lifestyle, suicide, accidents, and victimization by others.17 The mortality of persons with SMI is much higher than would be expected after release to the community, most often related to drug overdose, cardiovascular disease, suicide, and homicide.18 Notwithstanding the moral imperative and professional duty of physicians and other mental health workers to alleviate suffering and reduce risk, the treatment of mental illness in incarcerated individuals is mandated by the U.S. Constitution19 and by federal regulations in Canada.20 We have no doubt that a prison sentence has saved the lives of some persons with serious mental illness. It is not uncommon to hear of a returning inmate patient who did not connect with aftercare services (or dropped out of treatment), became noncompliant with medication, and resumed using illegal substances as a prelude to violating parole or committing another crime. Whether incarcerated or in the community, patients with SMI may lack the insight, understanding, or appreciation of their condition that is necessary to make a well-reasoned decision to accept or decline health care services. As discussed by Simpson et al., Lennox et al.21 reported that only 4 of 53 SMI patients with an aftercare plan including the involvement of a Community Mental Health Care team were still in contact with their team six months after release.

Despite the fact that prisoners with SMI are often lost to follow-up, Simpson et al. highlight the important role that mental health providers in correctional settings play in preparing their patients to return to society. Discharge (or re-entry) planning has long been regarded as a standard of care by the National Commission for Correctional Health Care22 and the American Psychiatric Association.23

Simpson et al. describe the use of assertive community treatment (ACT) teams in re-entry planning for former Canadian inmates with SMI, but they point out that traditional ACT services have not yet been shown to reduce recidivism.24,25 They suggest that the forensic assertive community treatment (FACT) model may be better, with a focus on pretrial diversion by taking referrals from jails, adding probation officers to the team, providing housing assistance, and offering treatment for co-morbid substance use disorders. Similar specialized programs geared toward the re-entry of SMI patients may also show promise. For instance, the Forensic Transition Team (FTT) in Massachusetts seeks to attend to the needs of persons with SMI exiting the correctional system and offers coordinated care services to both pretrial and sentenced inmates. Despite the voluntary nature of the program, outcome data26 show that 46 percent of former inmates with SMI were engaged in services after three months in the community. Of interest, patients who had misdemeanour charges for which they typically served six to nine months were the most likely to be lost to follow-up and to return to the criminal justice system.

Prison systems have advantages over other settings for the management of patients with SMI who are unwilling or unable to accept necessary psychiatric treatment voluntarily. Convicted individuals in the United States may be eligible for involuntary psychiatric medication in an administrative procedure modeled after Washington v. Harper.27 These inmates may be asymptomatic or greatly improved as they approach release, thanks to structure created by the presence (or likelihood) of nonemergency forced medication. When released from prison, they are no longer subject to the findings of a Washington v. Harper-type panel. Local civil regulations for forced medication are typically stricter and usually require inpatient civil commitment. Given the stability brought about by forced medication in prison, many of these patients will not meet criteria for inpatient civil commitment. Although some jurisdictions such as California have a formal process for the civil commitment of inmates with SMI who would otherwise be a danger in the community,28 such processes are the exception rather than the rule. Civil commitment imposes restrictions on liberty grievous enough, and different enough vis-a`-vis incarceration, to deserve additional due process.29 The typically strict standards for inpatient civil commitment often render hospitalization a short-term solution for those who, with treatment, will not become dangerous in the foreseeable future.30 Even when psychiatric medications mitigate the symptoms and behavioural problems associated with SMI, improvements in insight and judgment may lag behind other gains.

For select cases, involuntary outpatient commitment (IOC) may close the gaps in legal protections that create a revolving door of hospital and correctional recidivism. Most provinces in Canada have provisions for outpatient commitment in the Community Treatment Order (CTO). CTOs in Ottawa have been shown to reduce the number and duration of inpatient stays and to increase access for SMI patients to housing and mental health services.31 Outpatient commitment is legal in 45 states, although its implementation in the United States has been inconsistent. 32 The best example of the benefits of outpatient commitment in the United States is New York’s Kendra’s Law or assisted outpatient treatment (AOT). Research has shown that outpatient commitment reduces arrests, the number of hospitalizations, inpatient length of stay, homelessness, violent acts, and suicidal behaviour; improvements were noted in medication compliance and social functioning.33–36 For those enrolled in AOT for at least seven months, these improvements were maintained even after the patient was no longer mandated to outpatient treatment by court order.37 We believe that outpatient commitment, especially when it links former inmates with SMI to intensive treatment services, community support, and housing, would be a formidable tool to reduce recidivism and improve health care outcomes.

Involuntary outpatient treatment is not without controversy. A Cochrane review in 2011 concluded that the existing evidence from randomized controlled trials on outpatient commitment at the time was weak regarding outcome measures such as reducing hospital admissions, homelessness, and arrests.38 Criticisms of outpatient commitment include concerns about inadequate funding, diversion of public funds away from voluntary outpatient services, liability associated with managing dangerous persons outside of a hospital, unwillingness of judges and police to enforce the conditions of outpatient commitment, and the violation of a patient’s rights by using coercion to enforce compliance.32,39 Economic analyses to date suggest that, even with the cost of providing comprehensive outpatient services pursuant to Kendra’s Law in New York State, such services are cost effective32 and need not siphon resources from voluntary outpatient services.40 Similar to inpatient commitment, civil rights are protected by jurisdiction-specific criteria and the need for a court order for outpatient commitment. Whether a patient is appropriate for outpatient commitment is a clinical judgment requiring the same level of skill necessary for decisions to medicate, to reduce observation status, or to discharge from the hospital. It does not replace the option to hospitalize, but rather allows for the management of appropriate patients who are stable with treatment (yet reluctant to comply), in a less restrictive environment. Psychiatrists, especially forensic psychiatrists, can play a role in educating law enforcement and the judiciary about outpatient commitment and in advocating for appropriate enforcement.

Other strategies to alleviate the burden of serious mental illness in correctional facilities may also be worth considering. Mental health courts authorized to order a person with SMI into treatment in lieu of incarceration have shown promise for reducing recidivism and violence.41–43 Warrants for emergency room evaluations of suspected seriously mentally ill persons, such as the emergency petition process in Maryland, may serve as an early diversion from the correctional system.44 A post-conviction approach would be to coordinate with the parole department when developing an aftercare plan for an inmate with SMI. Defining treatment compliance as a condition of parole could have the same effect as outpatient commitment in reducing recidivism for those former inmates apt to respond to structured consequences for noncompliance. The difference unfortunately is that a violation of parole would be expected to result in reincarceration, rather than potential hospitalization in the event of a violation of the terms of an outpatient treatment order. Simpson et al. point out research showing that those with SMI are already at greater risk of recidivism because of technical violations of parole.45

In summary, we agree that serious mental illness in correctional settings in North America is a common and important problem. Bridging the effective management of SMI from the prison clinics to treatment centers in the community has implications for general and forensic psychiatrists in all settings. Providing comprehensive community services for these patients, whether through FACT teams, outpatient civil commitment, mental health courts, or other creative means, is a promising approach to maximizing functioning and minimizing risk, at the least possible cost to civil liberties for those already well familiar with not being free.

We commend Simpson et al. for addressing an important topic: the care and treatment of prisoners with serious mental illness. We welcome the authors’ conclusions, but we identify some problems that can often frustrate attempts to improve services to this group.

J Am Acad Psychiatry Law 41:514–5, 2013

Simpson and colleagues1 are to be congratulated for highlighting again a topic of great importance in forensic psychiatry. Within that part of the speciality that is responsible for the care and treatment of mentally disordered offenders, concern for the inmates’ mental status should not be overlooked. Experience gained through work of this kind will be helpful and complementary to the role of expert witness, assisting psychiatrists in speaking with greater confidence and authority during testimony. The authors highlight the rising number of prisoners who have serious mental illness (SMI) and the disproportionate increase in the number of prisoners from ethnic minorities who have higher rates of SMI. They pose several questions that arise from these trends.

One particular minority group to which reference is made in the review is Canadian First Nations people. The authors discuss the challenges that the increasing number of inmates from First Nations groups represents for mental health services. They helpfully exclude personality disorders and substance misuse from consideration, in that these are better treated as separate topics. They include suicide and attempted suicide in prison, which is perhaps an important and related topic. They conclude that SMI is becoming more common in the prison population. They discuss the effects of imprisonment on SMI and find that these effects are less severe than postulated. They question whether treatment in prison is effective, concluding that particular problems arise when prisoners are returned to the community but lost to mental health follow-up.

The rate of serious mental illness among prisoners has been of interest since the specialty of forensic psychiatry started to develop a strong identity during the middle years of the 20th century. For example, an early study in Scotland2 found significant rates of SMI in a Scottish prison at a time when the large Victorian psychiatric hospitals were still in existence and inpatient psychiatric beds were readily available. The process of deinstitutionalization has since led to an increased number of people who have SMI returning to the community without adequate followup. It is inevitable that some of these individuals will find their way to prison. Also, in view of considerable research that identifies that SMI increases the risk of certain types of offending,3 it is to be expected that the number of persons with SMI in prison will be greater than the number in the community.

Jurisdictions vary considerably in whether an offender with SMI is more likely to be committed to prison or to a secure hospital. Jurisdictions also vary in the options for transfer of a prisoner with SMI to a secure hospital, if there is a clinical need to do so. People in the community who have SMI often receive assistance from family and friends, but how can this support be replicated within a prison? Confidentiality and stigma are much more complex difficulties to deal with in prisons. Finally, can prisons ever be a safe and suitable location for the administration of medication without consent?

Forensic services could never meet the needs of all SMI prisoners and should not be responsible for doing so, since the bulk of offenders in custody with SMI are minor offenders who do not require specialist forensic care. Community services may be reluctant or downright unwilling to become involved with patients with SMI who have offended, even if the offence is minor. In some jurisdictions, effective aftercare can be arranged when prisoners with SMI come to the end of their sentences and are not fit for release. The prison health care service may refer them to local hospitals in the same way as if they had a physical condition. Further organizational complications arise within a health service that is predominantly in the private sector, as in the United States. These hindrances help explain the failure of community aftercare that Simpson and his colleagues identify.

Another aspect of the stigma faced by the SMI inmate is worthy of mention. It is often believed that prejudice in mental health services against mentally disordered offenders is a recent phenomenon, but that is not the case. There is evidence that such discrimination goes back a long way. In Scotland in the mid-19th century, when the first modern cellular prison was commissioned, it was found from the outset that mental hospitals or, as they were known then, asylums, in the surrounding community were unwilling to accept prisoners for treatment who were deemed to be insane.4 Another example of there being nothing new under the sun.

Despite these organizational challenges, the future, as Simpson et al. conclude, must ensure improvements in the quality of the mental health care of SMI prisoners. The challenges in working to achieve these advances are considerable and vary from one jurisdiction to another but, as the authors emphasize, they must be resolved.

The number of prison inmates is predicted to rise in Canada, as is concern about those among them with mental illness. This article is a selective literature review of the epidemiology of serious mental illness (SMI) in prisons and how people with SMI respond to imprisonment. We review the required service components with a particular focus on care models for people with SMI in the Canadian correctional system. An estimated 15 to 20 percent of prison inmates have SMI, and this proportion may be increasing. The rate of incarceration of aboriginal people is rising. Although treatment in prison is effective, it is often unavailable or refused. Many of those with SMI are lost to follow-up within months of re-entering the community. There is much policy and service development aimed at improving services in Canada. However, the multi-jurisdictional organization of health care and the heterogeneity of the SMI population complicate these developments.

(J Am Acad Psychiatry Law 41:501–9, 2013)

Canada’s 2008 incarceration rate of 116 per 100,000 people has been stable over recent years, and while similar to many Western European countries, is 15 percent of the U.S. rate of incarceration.1 The Canadian rate is predicted to increase, however, with the government’s tough-on-crime legislative reforms.2 With this, the mental health of Canadian prison inmates is a community concern and the Mental Health Commission of Canada has made it a matter of strategic importance.3 The purpose of this review is to summarize the current knowledge regarding serious mental illness (SMI) in prisons, with particular focus on Canadian prisoners. The findings of several recent meta-analyses covering aspects of SMI, substance misuse, and personality disorders in prisons, provide the context for discussion of the particular challenges for Canada in developing its service response to SMI in prisons. This review of the current provision of mental health services in Canadian prisons highlights the need for a coherent strategy to improve them. In this article, the term prison inmates includes pretrial and sentenced inmates. SMI refers to psychotic, bipolar, and major depressive disorders, although we will also discuss the risk and management of suicide in custody. Although substance use and personality disorders are very common in prisons and are often co-morbid with SMI, this article does not cover treatment needs for those disorders.

Epidemiology of SMI in Prisons

The prevalence of SMI in prisons was the subject of a comprehensive meta-analysis by Fazel and Seewald in 2012.4 Their review of 109 samples included 33,588 prisoners in 24 countries. Of the male prisoners, 3.6 percent had psychotic illnesses, and 10.2 percent had major depression. Of the females, the prevalence rates were similar, at 3.9 and 14.1 percent, respectively. These results are consistent with those reported in a 2002 meta-analysis by Fazel and Danesh.5 However, the 2012 study reviewed rates of psychosis in prisoners in low- and middle-income countries and found that the rates were significantly higher than in high-income comparators. Commonly, 15 to 20 percent of prison inmates have disorders that require psychiatric treatment, such as psychosis, major depression, and bipolar disorder.6,7 These studies and other recent reviews have indicated that the rates of SMI are substantially higher in prisons than in the general population.8,9 In the United States, this overrepresentation may be attributable to the significantly higher likelihood that persons with SMI will be jailed rather than hospitalized. 10 Teplin11 reported that individuals who display symptoms of SMI have a 67 percent higher probability of being arrested than do individuals who do not display such symptoms. Following arrest, individuals with SMI are more likely to be detained in jail (as opposed to being released on their own recognizance or having their cases dismissed) and, once jailed, they stay incarcerated 2.5 to 8 times longer than their non-mentally ill counterparts.12 Suicide is the cause in up to 75 percent of pretrial inmate deaths and 50 percent of sentenced inmate deaths. These rates are 3 to 11 times higher than in the general communities from which the prisoners are derived.13 Canadian prison suicide rates are similar to those in New Zealand and Australia and are generally lower than in Europe. The suicide rate of released inmates remains higher than that of the general population.14 Factors most strongly related to prison suicide include solitary cell placement, a life sentence, pretrial status, recent suicidal ideation, current psychiatric diagnosis, and treatment with psychiatric medication.15

Is Mental Illness Becoming More Common in Prisons?

It remains unclear whether the absolute number of persons with SMI in prison is rising simply because more people are being imprisoned, because more mentally ill people are being detected through better screening of those entering prison, or because the prevalence of SMI among those incarcerated is increasing. Three major studies have examined this question. In Washington state, Bradley-Engen et al.16 found no increase in the prevalence of major mental disorders from 1998 to 2006, although they did find a rise in co-morbid substance misuse. Sawyer et al.17 found no difference in the prevalence of mental disorder in young people in detention in 2008–2009, compared with that reported 10 years prior. However, a Finish study of psychiatric hospitalizations of prisoners18 found that 2.6 percent of prisoners had a diagnosis of psychosis in 1984 –1985, whereas 6.5 percent had the diagnosis in 1994–1995. There was also a significant increase in substance use, but rates of depression remained stable. Fazel and Seewald4 noted that in the 17 U.S. cross-sectional samples, there appeared to be a trend of increasing prevalence of depression over the 31 years from 1975 to 2005. However, no statistically significant increase in the prevalence of either psychosis or depression was found.

What Happens to the Severity of Illness During Imprisonment?

Being imprisoned is a stressful experience, and prisons are inherently stressful environments. However, the effects of these stressors on people with SMI have not been rigorously investigated. There are studies showing that acute psychotic symptoms19,20 and overall levels of distress21,22 decrease during the early period of incarceration. Hassan et al.20 noted that there was a reduction in symptoms among the sentenced men but not among pretrial male and female inmates, who continued to report persistent levels of distress. Longer periods of incarceration of SMI inmates may lead to more mental health symptoms.23 If SMI is left untreated, lengthy imprisonment may lead to disruptive, noncompliant, and aggressive behaviour in the inmate in reaction to the requirements of prison life.24 Psychiatric instability may be increased by placement in solitary confinement25 or sexual and physical assault while in custody.24 Further, institutional misconduct prevents individuals with SMI from participating in programs, thus limiting parole eligibility.26 In contrast, Fazel and Seewald4 reported that there was no significant overall difference in the prevalence rates of depression or psychosis between pretrial and sentenced prisoners in pooled cross-sectional studies.

Does Treatment in Prison Work?

Despite the availability of mental health treatment, inmates with SMI may choose not to participate in treatment because of concerns about reputation and confidentiality, prior experience, and individual demographics (e.g., minorities in prison report more negative attitudes about mental health services) or because of symptoms of mental illness.27 The presence of SMI often limits the individual’s insight into his illness and the need for medication and other health services.28 Skogstad et al.29 and Howerton et al.30 found that inmates who are suicidal may intentionally hide their mental state out of concerns about restrictions. Two studies found that about half of the most disturbed inmates received no services for a period of up to one year.31,32 A national U.S. survey conducted from 2002 to 2004 showed that a third of prisoners with diagnoses of schizophrenia or bipolar disorder were not treated with psychotropic medication.33 In terms of efficacy, a recent review by Morgan et al.34 suggested that interventions for offenders with mental illness effectively reduces symptoms of distress, improves offenders’ ability to cope with their problems, and results in improved institutional adjustment and behavioural functioning.

Mental Illness in Canadian Prisons

Canadian prevalence studies of SMI in prisons are summarized in Table 1. These findings are generally similar to those of international studies. Overall, SMI rates are as much as three times higher than in the general population,43–45 yet there is some variation between studies, given the smaller sample sizes. Similar to meta-analytic findings, there is no significant gender difference in SMI inmate prevalence rates.

From 1996–1997 to 2009–2010, the average annual suicide rate among Canadian federal inmates was about 3.7 to 7.4 times higher than in the age-matched general population.46 This rate is similar to the increased risk found in most Western nations.47 Serious self-injurious behavior with suicidal intent has been found to be similar across pretrial and sentenced populations and is higher in women (35%) than in men (20%) (Brown GP, unpublished data). Evidence from self-reported data and rates of prescriptions given for psychotropic medications suggest that the problem of SMI in prisons is getting worse. A recent federally commissioned report48 using self-report data found that 12 percent of male inmates and 21 percent of female inmates have significant symptoms of SMI on admission to a federal correctional institution. This rate is an increase of 61 and 71 percent, respectively, since 1997. However, the data have not yet been validated against a research-based diagnostic tool, and it is therefore unclear whether this rising rate of reported distress translates into increased rates of specific disorders. As regards prescription rates, the number of persons entering the federal system who are given psychotropic medication has nearly doubled in the past decade, to a 2008 rate of 21 percent of inmates receiving these medications while incarcerated.1

A comparison of needs assessments conducted by Correctional Services of Canada (CSC) in 1996 and 2002 also indicated that SMI is an increasing concern for federally sentenced women. A 1996 needs assessment for federally sentenced women found there were very few female inmates with a major mental illness (e.g. schizophrenia, psychotic depression, bipolar disorder, or an organic syndrome).49 By 2002, a report50 indicated that incarcerated women had a lifetime prevalence of schizophrenia of 7 percent and a lifetime prevalence of major depression of 19 percent (compared with community prevalences of 1% and 8.1%, respectively), in contrast to the “very few” mentioned in the 1996 assessment.49 The factors accounting for an increased prevalence of SMI in prisoners in Canada are very likely the same as those found in the rest of the developed world. As previously noted, inmates with a diagnosis of a mental disorder are less frequently granted full parole and, once released, are more likely to be reincarcerated for technical breaches of the conditions of release.43 In an Ontario, Canada study, Brown found that having a high number of severe symptoms of SMI correlated with a lower mean time to reincarceration; that is, those individuals with multiple symptoms were reincarcerated more quickly than those with fewer symptoms. However, time to reincarceration was not related to the severity of symptoms among SMI inmates (Brown GP, unpublished data).

A factor that may contribute to increased rates of SMI in Canadian prisons is the growing aboriginal prison population. While the First Nations, Metis, and Inuit aboriginal peoples comprise less than 4 percent of the general population, they account for 20 percent of the federal prison population.46 Aboriginal women offenders comprise 33 percent of the female inmate population under federal jurisdiction, which represents an increase of almost 90 percent in the past 10 years. The proportion of aboriginal inmates with SMI at admission increased from 5 percent in 1996–1997 to 14 percent in 2006–2007, but was down to 9 percent in 2008–2009.51 Male and female aboriginal inmates reported similar rates of serious self-injurious acts (30%) (Brown GP, unpublished data).

Necessary Service Responses

Livingston52 described minimum standards and best practices of mental health services in prisons. He noted that prison inmates have full rights to receive care appropriate to their health needs in accordance with internationally recognized principles.53,54 The U.S. Supreme Court55 has reaffirmed in California that medical and mental health care for prisoners is a right guaranteed by the Fourteenth Amendment of the U.S Constitution. Essential services for inmates include screening for mental disorders at reception, acute and non-acute treatment services, programs to meet their needs while in custody, and preparation for release and engagement with community mental health services on release.

In shorter stay prisons, the major functions are screening, assessment, and stabilization, with handover to community agencies on release. In longer stay (federal) institutions, services must include a full continuum, including pharmacological treatment, services for special populations, residential treatment for offenders with serious mental illness, crisis observation and intervention (which may take place in psychiatric wards at local hospitals), disciplinary housing treatment (higher security prisons or areas), inpatient psychiatric hospitalization, and prerelease treatment services.

Screening for SMI is a crucial component of prison mental health services and is usually performed by a primary health care professional at the point of reception into custody. The aim of screening tools is to detect persons likely to have an SMI who require more detailed mental health assessment. There are three major tools developed for this purpose. The Brief Jail Mental Health Screen (BJMHS)56 is widely used and comprises eight questions (six symptom questions and two historical questions). It has been validated against the Structured Clinical Interview for DSM-IV (SCID-L) for men and women.57 Another is a mental health screen of only five questions on past treatment and current criminal charge developed by Grubin58 in the United Kingdom. The third tool is the Correctional Mental Health Screen,56 which has a structure similar to that of the BJMHS, but with 12 items.

Evans et al.59 found that either the BJMHS or the Grubin tool worked adequately for detecting psychotic illness, but neither performed well at detecting depressive disorders, because inmates commonly endorse depressive symptoms at entry into prison. Screening for suicide risk and follow-up assessments are essential, and policies for suicide risk reduction should be built into the design and function of prisons.60 Bauer et al.24 defined treatment for inmates with SMI as including basic mental health and rehabilitation services, the latter focusing specifically on reducing criminal behavior and recidivism. Rehabilitation should attend to both mental health treatment and criminogenic factors most commonly embraced by the risk-need-responsivity model.61 Sawyer and Moffitt62 noted that, although reducing recidivism is an important goal for those working within the criminal justice system, correctional treatment is often focused on more proximate goals, such as symptom reduction and assisting inmates with mental illness to cope in the correctional environment. Specialized psychiatric care units, also known as residential treatment centers, have been identified as best practice for dealing with the difficulties associated with mainstreaming inmates needing mental health services.52,63

Specialized care units are most appropriate for inmates with mental health problems who are unable to function adequately in the general offender population, but do not require hospitalization. 64,65 The purpose of these specialized care units is to enable adequate observation of inmates with SMI and to stabilize and transition them into the prison mainstream. These units have been associated with reductions in institutional crises and management problems and improvements in inmate quality of life.64

Preparation for release and engagement with follow-up are essential. In a systematic review, Fazel and Yu66 found that persons with SMI have a moderately higher risk of repeat offending than do persons without SMI and noted that improvements in their treatment and management while in custody and after release have the potential to make a positive impact on public health.

Comprehensive discharge planning should follow community standards and include a guaranteed supply of medication and appointments with outpatient clinics, psychiatrists, or other counseling services. The involvement of prison and parole authorities is vital in achieving successful care transition into the community. A recent study found that nearly all of those with SMI are lost to follow-up after six months in the community.67 This population can be difficult to engage on a long-term basis and may require special assertive community treatment (ACT) team involvement. After release and while on parole, traditional ACT models may improve engagement and symptom reduction, but they do not appear effective in keeping persons with mental illness out of the criminal justice system.68,69 Enhancing ACT to include criminogenics (so-called forensic ACT or FACT) has a limited, but promising, body of literature to support it. Lamberti et al.70 performed a national survey of FACT teams in the United States and identified a set of common structural elements that distinguish them from traditional ACT models. These elements include the goal of preventing arrest, receiving referrals from local jails, incorporating probation officers as FACT team members, and having a supervised residential component for consumers with SMI and substance abuse disorders. Jennings68 argues that emerging research from the forensic continuum of care model suggests that community aftercare programs such as ACT can be enhanced by pretreatment in prison or in a community residential treatment precursor.

Challenges

There are two main challenges in meeting the mental health care needs of prisoners in Canada. The first relates to the multi-jurisdictional context of health care provision, and the second relates to the demand for services that outstrip the current resources. In Canada, the provision of health services is a provincial responsibility, and each province and territory has its own health system and legislation, including civil commitment laws. Mental health care in all correctional institutions is governed by the mental health act of the province or territory in which it is located, regardless of whether the institution is a federal or a provincial one. The Criminal Code derives from federal legislation, but pretrial inmates and all inmates serving sentences of less than two years are a provincial responsibility. Federal corrections, known as Correctional Services of Canada (CSC), provide services for all prisoners sentenced for two years or longer. Service and delivery of health care in federal prisons are mandated by the Corrections and Conditional Release Act of 1992.71

There is no Canadian health service entity that could undertake delivery of services in all correctional institutions; to create one would most likely require legislative change. Thomas72 concluded that a full transfer of health care provision to a new pan-Canadian body is untenable at this time and that the focus should be on extending the partnership models where CSC maintains full responsibility for health care, but partners with the regional Ministries of Health for the delivery of specialized services. As it stands now, federal regulations require the provision of “essential health care” and “reasonable access to mental health care.” Every institution is required to provide an appropriate clinical response for inmates with an SMI, which includes being placed under close observation of trained staff, assessed by a health professional, and provided support and treatment. A specialist should be available for consultation “at all times.” Transfer to an appropriate health care facility should be available “as soon as possible.” Before disciplinary action is imposed on an inmate identified as having an SMI, consultation should take place with a mental health professional. Inmates with serious acute or chronic mental health problems should be housed in an environment that offers a safe and therapeutic milieu.46 In recent years, this CSC mandate has necessitated significant increases in resources for mental health services in federal institutions.

Progress

In 2004, the CSC instituted a Mental Health Strategy that included an Institutional Mental Health Initiative (IMHI) focusing on intake screening, assessment, and primary mental health care teams. Included in the IMHI is a computerized intake screening system to signal inmate mental distress, which can then be further assessed with a view toward developing an individualized plan by a Primary Mental Health Care Team. To assist in SMI inmates’ reintegration into the community, the CSC implemented a Community Mental Health Initiative (CMHI), which included hiring new staff (discharge planners, mental health care specialists, and parole officers), providing staff training, and working with community health organizations. The IMHI coordinates with the CMHI teams to provide a continuum of care.73

CSC has also established five specialist psychiatric care units, called regional treatment centers. CSC acknowledges that bed capacity in these centers meets only 50 percent of the identified need,46 resulting in occasional double bunking of inmates in segregation. Notably, three of the five women’s facilities in the Atlantic, Quebec, and Prairie regions have an exemption that allows double bunking of women offenders in their secure (maximum security) units. In some provinces, CSC has an arrangement with a provincial hospital to accept transfer of inmates needing acute mental health intervention. This model has shown positive results, and the CSC has recommended expanding this availability for SMI inmates who cannot be treated at specialized psychiatric care units.72 The tragic death by suicide in 2007 of Ashley Smith, a 19-year-old woman detained in a federal institution, has been a significant stimulus to improve services. Several investigations produced broad recommendations for change and spurred dialogue between the CSC48,72 and its critics.74,75 Correctional Investigator Howard Sapers74 recommended a broad review of the provision of mental health care in correctional environments and the consideration of alternative models of care. Needs identified for improvement include training for correctional staff regarding care provision for inmates with mental health needs, triggers for notification and investigation (including self-injurious acts and lengthy segregation periods), consultation by mental health professionals, and improvement in the ease of transfer to a specialized care unit or a hospital.

CSC responded to the call for considering alternative models of care.72 Given the complexities of geography and differing provincial health systems, a one-size-fits-all approach was not feasible across Canada. Instead, a continuum of care was presented that ranged from having CSC be responsible for the health service but contracting various mental health professionals to staff clinics (the usual service model) to the full transfer of responsibility of all health service delivery to provincial health authorities. The latter has been accomplished in some provincial institutions in Nova Scotia and Alberta, as it has in other international jurisdictions such as Norway and the United Kingdom. These transfers, not only of services but also of the legislative responsibility of health care provision, have been costly; a similar proposal in New Zealand failed primarily because of funding concerns. The transfer of health services from corrections staff to health-trained and dedicated staff seems, prima facie, to be beneficial with respect to access, quality, and standards of care. Such a shift in responsibility allows for more effective transition on reintegration into the community, and a strengthening of the voice of mental health services in the correctional environment.

As noted, the multi-jurisdictional context of the Canadian health system makes planning for prison mental health services complex. It was only in 2007 that the government of Canada mandated that the Mental Health Commission develop a national strategy for mental health care.3 This document was released in 2012. It included recommendations to reduce the overrepresentation of persons living with mental health needs in the criminal justice system and to provide appropriate services, treatment, and support to those who are in the system. Although progress has been made in meeting the mental health care needs of Canadian prisoners, further resources and planning are necessary. For example, a proposal to create dedicated intermediate care units on a regional basis to support specialist psychiatric care units has not been funded. These units fall between care provided at a mainstream correctional institutions and acute inpatient care offered at the specialist psychiatric units.46 Further, barriers to providing mental health care in the correctional system include poor recruitment and retention of mental health professionals, inadequate bed space at specialist psychiatric care units, lack of funding, underutilization of clinical management plans to treat high-needs mentally disordered offenders, and over-reliance on segregation to manage offenders with mental health problems.46,76 Wait times for psychiatric assessment have been increasing in the past decade because the increasing number of persons to be assessed is outstripping the forensic mental health services’ ability to respond.77

Discussion

This review touches on some key points in the large and expanding area of public policy, clinical need, and research. Persons with SMI in the criminal justice system are some of the most marginalized, disenfranchised, and underserved patients in need of mental health care. Their increasing number appears to be a result of both tougher criminal justice policies and limited community mental health services. They are hard to engage, frequently receive few or no services, and can rapidly drop out of care after release into the community. The lack of continued care leads to problems of disability, social instability, substance misuse, illness, and criminality. These problems are not insurmountable. Inmates with SMI respond to treatment and benefit from well coordinated services. These services must be run in partnership between health and correctional systems. Given current government policies that cause an increase in the number of prisoners, the need for service development is becoming more acute and demands a coherent service and policy response. We know too little about the trends, needs, and service models for persons with SMI in prisons. We also have limited understanding of the effects of incarceration on persons with SMI.

We cannot assume that the problems will be the same for male and female inmates, for pretrial and sentenced populations, and for aboriginal groups. However, as most people are cycling through prison for short periods, imprisonment represents a vital opportunity for detecting the need for mental health treatment and attempting to link people with local community mental health services in concert with probation services after release. The successful FACT models point to a way of doing this more effectively than simply expecting mainstream community mental health services to provide care.

This article has focused on in-prison and point-of-release concerns, but comprehensive services in this area must include diverting minor offenders before incarceration through court and jail diversion programs and liaison with police services. Further, substance misuse treatment must be included along with the package of care that inmates receive during incarceration and on release.52 This is a challenging but very important area of service development. Unfortunately, too often the health and correctional sectors place the blame on each other for these problems. Corrections attribute the increased prevalence of mental illness in prisons to a failure of the health care system. Health says that it is a result of criminal justice policy and poor social environments. Regardless of the explanation, prison inmates with SMI require integrated health and correctional responses. This problem is not the responsibility of one sector or another; it is a human challenge for both.

I get parking tickets now and again. It happens. Here’s how the conversation went semi-recently:

I got a ticket

Oh, that sucks.

Kind of.

You’re just saying that, of course you’re pissed.

Nope, not pissed at all. In fact, I get a slight rush of happiness when I get a ticket.

uh… wha?

Growing up in Thornhill, Ontario was a standard, Canadian, secular-cloistered environment. When I started driving, at around 16/17, I would occasionally get parking tickets and feel hard-done-by. When I was driving and heard sirens behind me, my stomach would drop. Thankfully I never got a speeding ticket, but still, I recall the quasi-instinctive fear of the law. This feeling more or less diminished throughout my life, but the residues remained; tickets are a bad thing.

In Chad, there is no rule of law that is worth mentioning. There was a local administrator in Farchana, and often I was trotted along to negotiations now and again as it was viewed as a sign of respect to bring medical team members to meetings. The fellow could be abrasive and accusatory, and other times could be downright pleasant. He could do whatever he wanted. He had a type of power that is unknown in other parts of the world. He could set the truth conditions for the world around him, if only a small chunk of the world. That which he said was wrong was wrong, and his word was generally unquestionable. Negotiations were delicate, to say the least.

This fellow casually stated one afternoon, during a meeting, that he allowed MSF to maintain its medical mission with relative safety. Nobody doubted this.

During a car-jacking, as I mentioned in a previous post, an ex-pat humanitarian aid worker from France was shot in the head. His death may not have been entirely accidental, and the repercussions for the local community was effectively absent. This was a sanctioned occurrence, it appeared.

Harsh, arbitrary and radically discretionary punishments, meted out by the local warlord was the way of life. Human rights were negligible. Women’s rights were almost non-existent. This was the furthest thing from a meritocracy I had ever seen, and it made me sick to my stomach. It struck me for the first time how crucial the rule of law is to undergirding civilization. (I wondered what other fundamentals were necessary and sufficient, such as payment of living wages, adoption of the scientific method, etc.)

Back to modern day Toronto. The fact that one can leave their car for an extra 20 minutes for which payment was not made, and there is a surveillance system that is generally fair, universal, enforceable and contestable is a great achievement. A seemingly small thing, but flowing from an absolutely necessary, and in a way, a wonderful system. Even if I’m out $30 for tarrying a bit.

Fast-forward to 2013. I’ve been working as a forensic psychiatrist at CAMH in Toronto for about 4 years, and it’s been a fascinating apprenticeship and practice at the intersection of psychiatry and the law. A multidisciplinary team assesses, treats and risk-manages, aiding those with mental illness in transitioning back to the community. But this post is not about the job. It’s more about reflecting back on the missions, some years past.

First, a bit about Sudan. About three months after returning from Chad, in mid-2008, I was asked to join a mission in Nyala, Sudan. Kalma Camp was, at the time, the largest refugee camp in Darfur, and some said that it was the largest in the world, with about 150,000 internally displaced persons (IDPs). It was a troubled time, of course, but another emergency had reared its head. The sitting president was being investigated for charges of war crimes of the worst kind, up to and including genocide. He had been tolerating humanitarian aid in the country because to not do so looked pretty bad. Well, in the wake of the impending indictments, he decided that such bad press was the least of his problems, and he was moving to kick all humanitarian aid projects out of the country, and mental health was going to go first. The mental health staff speak to people, and in gathering stories, so the presidency was concerned, might collect information that would be injurious to his human rights record.

I was only to interact with MSF staff, and have no direct patient contact. No journalism of any kind. No cameras. No notes were to leave the country. Any transgression would result in being jailed. This was made very clear to me, and I signed several Arabic language documents (which my translator struggled to explain). My translator impressed upon me that even suspicion of wrong-doing is enough to be jailed. And Sudanese jails are the stuff of nightmares. These people were not fucking around. Blogging was, of course, verboten.

So MSF needed a psychiatrist to go in ASAP and work with three local doctors on matters of assessing, diagnosing, treating and managing persons with schizophrenia. There was a small and closing window, so to save time, MSF sent me to Nairobi, Kenya to try and get a Sudanese visa more quickly. It took some doing, but a week later I was on my way to Khartoum.

The worldwide prevalence of schizophrenia, fairly consistent across all ethnic and social strata, is about 1% of the population. So in a camp the size of Kalma, one would estimate, all things being equal, that there would be about 1500 persons with this endogenous psychotic disorder. But that’s a big assumption, the equality part. The political situation was, to put it mildly, chaotic. Surviving a dangerous situation, especially a protracted one, takes great organization, stamina and resolve. Vulnerable populations such as the elderly, children, and persons with physical or mental deficits, are less likely to stay alive without support structures in place, and these very structures were being torn apart by the violence. It was impossible to state how many persons with schizophrenia were in the camp, but the project had about 200 persons for whom they were providing regular care.

If you want to do emergency psychiatric work, and get the most immediate, profound and potentially enduring benefit for the population, there are many strategies. One of them that should be included is to find the schizophrenic population and, in consultation with their family or other supports, offer low doses of antipsychotic medication.

Medication is the single best intervention for schizophrenia, and while it does not cure, it controls many symptoms quite well in a large percentage of the treated. Haldol, an older and well-established medication, was available in large supply, and was available on the open market (through pharmacies; no prescriptions are necessary in Sudan). Of course, MSF had its own supply chain, and the medications were of the same standard as those provided to anyone in Canada. But while emergency and relief humanitarian aid does the best it can, and for a whole host of reasons, a person with schizophrenia or their family may need to access antipsychotic medications in the future and not have access to an established clinic, and thus it is very helpful to have a medication that has a local supply chain.

Haldol (or haloperidol) is still used regularly by Canadian psychiatrists, although often for more acute psychosis accompanied by agitation and aggression. It is in the Canadian guidelines for medical management of schizophrenia. The well-worn prescribing mantra of “start low and go slow” fit the situation. Most of the persons with whom mental health staff have contact in Canada are well known to the system, and have been tried on one or more antipsychotic agent, and usually in high dose and even in combination with another medication. In Kalma Camp, by contrast, almost every person treated was neuroleptic-naïve, which meant that they had never taken a medication of this drug-class. Haldol came in 5mg increments, and to allow for some sort of standardization, we cut them into quarters (1.25mg per piece) and started there. Avoiding side-effects while getting the best effect with the lowest dose was the goal, as it always is. And it turned out that 1.25mg, twice a day, was the optimal strategy.

One day a fellow with schizophrenia was brought in by his family for follow-up care. He had been started on Haldol before I arrived in the camp, and I was seeing him at what might have been his “best baseline” or mental status at his best treatment level. I’ll call him Abdul, although for the life of me I can’t recall his name… I kept no notes, something that was prudent, but most regrettable nonetheless. Abdul was in his early-20s. His family provided most of the history: Abdul started exhibiting psychotic symptoms (the harbingers of what would become fully blown schizophrenia) in his mid-late teens.

While he was once gregarious, athletic, and sociable, he became more reserved, isolated, and unable or unwilling to engage in basic behaviours such as maintaining hygiene, social protocols and schooling. Unfortunately, he also developed strong paranoia, and believed that his brother was trying to do him harm. About two years prior to when I met Abdul, he became aggressive, and killed his brother. His family recognized that he was ill, and was not to be punished, but they had to contain the risk, and chained him to a log. Abdul could move slowly from one place to another, and was cared for by his family as best they could. The family found antipsychotic medication in the marketplace (the pharmacy medications, likely of purer provenance, were too expensive), which had some beneficial effect, but not consistently so. The family heard of the MSF project, and travelled between camps in order to find treatment for Abdul. He had been treated with MSF-provided antipsychotic medication for about a year prior to my having seen him. Abdul was pleasant, conversant and fairly engaging, albeit somewhat emotionally detached, and he mainly answered questions that were posed to him rather than speaking spontaneously.

He was well-dressed, living with his family, and was taking part in the family business. He was betrothed to be married. Abdul recalled little of the incident leading to the death of his brother, and his family jumped in and explained that this was not the “real Abdul… it was the sickness in him.” Abdul recalled being chained to a log, and while it was deeply unpleasant for him, he recognized on some level that his family was acting in his best interests, and he did not appear to harbour any resentment for it. He indicated that he needed the medication to stay well, and that the “magic quarter” had saved his life. I agreed that his family and the magic quarter (of Haldol) had saved his life. The status of the MSF project was in jeopardy, and the Abdul and his family were understandably quite worried about what would happen if the free medicine became unavailable. They were provided with a solid supply of the medication. To this day, I wonder how Abdul is doing now.

The structure of the day involved waking up early in Nyala, eating a perfunctory breakfast, and hopping on the “landy” (Land Rover) that took 45 minutes to get to Kalma Camp. The bench seats in the back were simple wood planks, and six or eight people would cram in. The terrain was rough. I had tweaked my back (degenerative discs are not kind to the aging), and could feel the bumps. We’d arrive at camp, and I’d head off to meet with the three local doctors. We spoke in English, but also had a translator for some of the trickier concepts. We saw patients with their families all day, and made time for a lecture over the lunch-hour. One after the next, each doctor would take turns assessing, presenting the case to the team, proposing a treatment strategy, and then discussion and implementation. This happened as many as 20 times a day. Rough and ready guidelines flowed from these discussions, and they were translated in Arabic. MSF encouraged the guidelines to be distributed widely, and many photocopies were left with the Sudanese doctors.

By the end of my two months, the three doctors were not only managing this population well, but were holding their own lectures for other staff, and training what would be their support staff for the continued clinic. It was a resounding success. I was elated, proud to be a small part of MSF and the mission. And it felt like something new, something that I resolved not to forget, as it is so easy to. I was not a simple cog in the machine out there, but a part of something larger than myself in which I had a crucial role. I was part of something that would not have taken place had all the elements not been in place. There was a type of satisfaction in this work that does not often come from other types of work. It was brief, meaningful, and nourishing for that core of the self for which we have so many names but nothing concrete.